Clinical anatomy is human anatomy applied to medical sciences. The study of the human body is only relevant if the subject matter is correlated very well with the clinical problem. It becomes more relevant if it is clearly demonstrated that what the students are learning today will be important in their subsequent studies and in their practice in the art of physical therapy.

This module covers the following regions of the human body: 1. The upper and lower extremities; 2. the back.

The following are the objectives of this course. First, is to be able to know the importance of the regional anatomy of the limbs and back in relation to the practice of your course, that is Physical Therapy. (If you want to explore further by becoming a doctor of medicine, then, the importance of these regions as site of clinical interest). Second, to be able to know the anatomic structures found in these regions and their relationships. Third, to be able to know how the form of these anatomic structures relate to their function. Fourth, is to relate the different clinical conditions that may arise as a result of dysfunction of the form and functions of these anatomic structures.

By definition, Human Anatomy is the study of the gross or macroscopic structure of the human organism. It is the BASIC MEDICAL SCIENCE dealing with the structure and function of the human body. During ancient times, it is purely descriptive of the form of the structure without any regards to its function. Neither was there clinical correlation. Then later Human Anatomy was mainly concerned with the form and function of parts of the body that could be demonstrated by dissection. This method of study is still widely used because it provides an orderly and consecutive display of the structures of the body. It also helps in obtaining a three dimensional concept of its parts. Although this method of studying the body, called macroscopic or gross anatomy, is closely associated with surgery, it forms an essential basis for all branches of medicine and dentistry. Then as time evolves gross anatomy became correlated with development (Embryology), function (anatomy and physiology) and clinical significance (pathologic anatomy, clinical anatomy). Considered as the oldest medical science, human anatomy traces its origin to the Greek civilization. It is one of the disciplines taught by HIPPOCRATES in the 4th century BC. The Hippocratic Oath is attributed to him. It was Hippocrates who one wrote and stated, “The nature of the body is the beginning of medical science.” Another famous Greek physician and scientist, ARISTOTLE, (384-322 BC) was credited to be the first person to use the word “anatome,” a Greek word meaning “to cut up” or, as we now say, “to dissect.” In those days, to perform an “anatomy” was to do dissection. These two words are no longer synonymous. Dissection is a technique used to learn gross anatomy, whereas Anatomy is a discipline or field of scientific study dealing with all branches of knowledge which are concerned with the study of bodily structure.

Although essentially a morphological science (that is, concerned with the form and structure), anatomy has never been just that. In the writings of Hippocrates and Aristotle, the form and function of certain parts of the body were described. Many of their ideas were found to be true, some were later proven to be false. Discussion of the function of a part or organ has always been included in anatomy. PHYSIOLOGY, at one time, was part of the discipline of anatomy, but as many new methods of investigating function were developed, it became a separate discipline. When the word anatomy is used without qualification, it is meant to be gross anatomy. Human anatomy is considered as the mother science of clinical medicine and, as such, is the foundation of clinical branches of medicine like Internal Medicine, Surgery, Pediatrics and Ob-Gynecology. From Human anatomy came the following branches of medical sciences: Pathology (also known as Morbid Anatomy), Physiology, Neuroanatomy, Histology and Cytology (Microscopic Anatomy), Embryology (or, Developmental anatomy), Physical Anthropology.

Above are the subdisciplines that developed later from the basic medical sciences. More subdisciplines are being developed like Medical Robotics, Biomedical Engineering, Tissue Engineering, Genetic Engineering, etc.

The subject of Anatomy is being taught in different ways. In the high school and in the undergraduate medical related courses the most common approach is the Systemic Anatomy. In the higher year of the undergraduate medically related courses like Nursing, Medical technology, the approach is Functional anatomy like in Anatomy and Physiology. In Medicine, however, the usual approach is Regional Anatomy and Clinical Anatomy. Fortunately, since the course in Physical Therapy is basically a medically related, Regional Anatomy/Clinical Anatomy is the logical approach.

In Systemic Anatomy, one of the approaches in the study of anatomy is to organize it according the functional system. Thus, the Integumentary System is solely an anatomical study of the skin structure; or, the Musculoskeletal System is an anatomical study of the musculature. In this kind of Systemic anatomy, the particular functional system can be studied in isolation.

The other type of Systemic Anatomy is to approach the study by ORGAN SYSTEMS. Example, the skeletal, articular and muscular and nervous systems constitute the locomotor system of the body. Although the function of locomotion is directly related to the muscles, bones, joints and ligaments, other system are intimately involved as well. The nerves to these structure stimulate them to act; the heart, arteries and veins of the circulatory system supply O2 to them and remove the waste from them. In this kind of system, none of the organ system functions in isolation.

Regional Anatomy is the usual approach of teaching anatomy in the medical school and in Physical Therapy. It is based on the organization of the body into parts: the head, neck and trunk( which is further subdivided into the thorax, abdomen, pelvis/perineum, back) and the paired upper and lower limbs. Each region is not an isolated part and must be studied in relationship with the adjacent regions and the body as a whole. It is also important to note that in this approach, emphasis is placed on the relationship of various systemic structures( e.g., muscles, nerves, skeletal system, arteries and veins and the lymphatics) found within the particular region. It is also very important to emphasize the SURFACE ANATOMY is essential part of regional anatomy. In surface anatomy, it provides information on what structures are visible and/or palpable( perceptible to touch) in the living body at rest and in action. Surface anatomy, when applied to the clinical aspect, is actually a component of Physical examination. For example, in dealing with a patient whose complaints is abdominal pain in the epigastric region , a health worker must be able to think of the possible abdominal structures that may possibly cause abdominal pain in this particular part of the abdomen. Another example is low back pain. This kind of subjective complaint is universal. There are several structures that may give rise to low back pain. By inference based on PE and laboratory findings, the organ causing the back pain could be isolated.

Much can be learned from observing the surface of the body. For example, palpation of the pulse is one of the routine evaluation of the body. You will only know where to palpate it if you know surface anatomy of the arterial vessels where these can be felt superficially. The study of the surface features of the superficial landmarks of the structures that are visible or palpable (perceptible to touch) is called LIVING or SURFACE ANATOMY. The fundamental aim of surface anatomy is the visualization (in the “mind’s eye”) of structures which lie beneath the skin and are hidden by it. It forms the basis for the physical examination of the body that forms a part of physical diagnosis.

Above is an example of surface anatomy. At the left side diagram are the structures projected on the surface of a living person.

The human body is arbitrarily divided into 8 regions, namely: 1. Head 2. Neck 3. Upper Limb 4. Thorax 5. Back 6. Abdomen 7. Pelvis/Perineum 8. Lower Limb In each region, emphasis is placed on the relationship of various systemic structures (e.g. muscles, bones, nerves, arteries , veins, etc.) found within the region. Each region is not an isolated part and must be considered into the context of adjacent regions and of the body as a whole.

In Clinical Anatomy it is the application of anatomy to the different clinical conditions encountered in the clinical practice. It encompasses both the regional and systemic approaches. Example: A patient comes to the emergency room after a motorcycle accident. On xray, the patient has fracture at the middle third of the left humerus. PE findings include the following: 1. wrist drop deformity of the left hand; 2. no active wrist extension; 3. loss of active finger extension; 4. loss of sensation at the lateral aspect of the middle third of the left forearm and the dorsum of the left hand. Anatomically, how do you explain the wrist drop associated with the humeral fracture?

Anatomy, being a descriptive discipline, has its own language. Anatomy, in itself, is the basis of the language of medicine and dentistry. As a beginner of anatomy, you will learn a fascinating new language consisting of at least 7500 words. This language is shared by all the health professionals, teachers of anatomy and other health related workers worldwide. This language evolves from the ancient languages of Greco-Roman world. Later, eponyms became added to it, although eponyms are not officially recognized and its used is being discouraged. Currently, The Terminologia Anatomica: International Anatomical Terminology (Federative Committee on Anatomical terminology, 1998) contains the accepted glossary of Anatomy.

The Anatomical Position is a point of reference to which all anatomical descriptions are described and expressed. This point of reference is necessary to ensure that the descriptions are not ambiguous. The Anatomical position refers to a person(or, people)- regardless of the actual position he( or, they) may be in. However, the point of reference is that of a person is erect ( or lying supine as if erect) with the: 1. Head, eyes(gaze), and toes directed anteriorly(or forward); the upper limbs by the sides with the palms facing anteriorly; the lower limbs close together with the feet parallel and the toes directed anteriorly.

Anatomical descriptions are based on 4 imaginary planes that intersect the body in the anatomical position. There are many sagittal, frontal and transverse planes, but there is only one median plane. 1. Median (median sagittal) plane is the vertical line passing longitudinally through the center of the body, dividing it into right and left halves. 2. Sagittal planes are vertical planes passing through the body parallel to the median plane. It is helpful to give a point of reference to indicate the position of a specific plane. For example, a sagittal point through the midpoint of the clavicle. A plane parallel and near the median plane may be referred to as a PARAMEDIAN PLANE. 3. Frontal (coronal) planes are vertical planes passing through the body at right angles to the median plane dividing the body into anterior(front) and posterior(back) portions-, for example, a frontal plane through the heads of the mandible. 4. Transverse planes are planes passing through the body at right angles to the median and frontal planes dividing the body into superior(upper) and inferior(lower) parts. For example, a transverse plane through the umbilicus. Radiologists refer to transverse planes as transaxial planes or simply axial planes

The movement of part of the body in relation to the other part occurs in a particular axis. An AXIS is defined by the intersection of any two planes. There are 3 of these axes. 1. VERTICAL AXIS is defined by the intersection of the midsagittal and midcoronal planes; 2. ANTEROPOSTERIOR AXES are defined by the intersection of the transverse and sagittal planes; 3. BILATERAL AXES are defined by the intersection of coronal and transverse plane.

Various descriptive words, arranged as pairs of opposites, describe the relationship of parts of the body in the anatomical position and compare the position of two structures relative to each other. Example, the eyes are superior in position in relation to the nose, whereas the nose is inferior to the eyes.

Anatomic adjectives are descriptive words arranged in pairs of opposites. These adjectives describe the parts/regions of the body based on the anatomical position, or, describe the parts/systems/regions in relation to each other. Example: the triceps muscles solely occupy the posterior compartment of the arm. On the other hand, several muscles occupy the anterior compartment of the arm.

PROXIMAL and DISTAL are directional terms used when describing positions- for example, whether structures are nearer to the trunk or point of origin (i.e., proximal), or, farther from the trunk or point of origin (i.e., distal). Example as describing structures near to or far from the trunk: The shoulder joint is more proximal to the elbow joint; or, the elbow is more proximal to the wrist joint. The sternoclavicular joint is more proximal that the acromioclavicular joint. The wrist joint is more distal than the shoulder joint.

Dorsum refers to the superior or dorsal (back) surface of any part that protrudes anteriorly from the body, such as the dorsum of the foot, hand, penis or tongue. It is easier to understand why these surfaces are considered dorsal if one thinks of a quadripedal plantigrade animal that walks on its soles, such as a dog. The sole indicates the inferior or bottom of the foot, much of it is in contact with the ground when standing barefoot. The sole is also called the PLANTAR side of the foot. The PALM is the flat or VENTRAL side of the hand, excluding the 5 digits, and is the opposite of the dorsum of the hand.

There are terms that are combined like inferomedially or superolaterally and these combined terms describe intermediate positional arrangements. The term “inferomedially” describes a structure or a part of the body that is nearer to the feet and closer to the median plane. Or, the term “superolaterally” describes an anatomic structure or part of the body that is nearer the head and farther from the median plane.

The terms of laterality describe whether the structure is paired or occurring in both sides (right and left), or, it may be present on one side. The terms of laterality also describe a condition occurring in two parts of the body either on the same side or in the opposite side. Thus, a bilateral cystic kidneys describe a condition that affects both the right and left kidneys or; bilateral femoral shaft fractures describe fractures involving both the right and left femora. Fracture of the left humerus with ipsilateral fracture of the radius means that there is also a fracture of the left radius. In fracture of the left femur with contralateral fracture of the tibia simply means that there is a fracture of the tibia in the opposite or right side of the lower limb.

Terms of movement are words arranged as pairs of opposite. These describe movement of the limbs and other parts of the body in relation to the anatomic position. Most of the body motions take place at joints. These joint movements are based on the axes through which the movement evolved and through the anatomic plane.

The term “flexion” means bending of a part or decreasing the angle between body parts. The term “Extension” means straightening a part or increasing the angle between body parts. Except for the thumb, flexion and extension movements are in the sagittal plane.

The terms “Abduction” and “Adduction” describe a motion of an anatomic structure of the body or part of the body away (abduction) or toward (adduction) from the median plane of the body in the frontal(coronal) plane. For example, moving the upper extremity away from the trunk laterally, or, the lower extremity away from the center of the body or from the opposite lower extremity laterally is Abduction. Adduction, on the other hand, the motion is in the opposite direction. In movements of the digits like the fingers and toes, abduction means spreading them, and adduction means drawing them together.

Rotation means a motion around an axis. In a long bone the axis is located at the center of its mass at its entire length. Rotation as a movement of an anatomic part of the body occurs in two directions- medially and laterally. Medial rotation turns the anterior(or, ventral) surface medially. Lateral rotation turns the anterior(or ventral surface) laterally.

Elevation/depression are generally up and down movements about horizontal axes. Movement of an anatomic part or a structure cephalad like shrugging of shoulder upward is called elevation. The opposite motion being depression.

CIRCUMDUCTION describes a motion of the limbs (upper and lower extremities), or parts of them in which a sequence of movement of flexion, extension, abduction and adduction occur.

Pronation/ Supination are opposite terms used to describe a rotational motion involving the forearm and hand. Pronation is medial rotation of the forearm and the hand so that the palm of the hand faces posteriorly. Supination, on the other hand, is lateral rotation of the forearm and the hand so that the palm of the hand faces anteriorly.

The terms “ inversion and eversion” describe rotational movement that occurs in the foot. INVERSION is a rotational motion in which the plantar surface of the foot rotates inward or medially. EVERSION rotates the plantar surface of the foot laterally.

Protraction/Retraction are opposite terms that describe outward and inward movement. PROTRACTION moves a structure anteriorly like jutting out the jaw or rolling the shoulder anteriorly. RETRACTION moves the structure to its original position or to the median like in withdrawing a protracted tongue into the oral cavity.

There are specific movements that are characteristics of a particular anatomic structure. The terms INTORSION and EXTORSION describe rotational motion of the eye about an axis through the pupil with the top of the eye as the reference. The terms OPPOSITION and REPOSITION are terms describing the motion of the human thumb which is the most important digit of the hand. OPPOSITION is the motion that places the tip of the thumb in contact with the tips of the other finger like the act of pinching.

The body, as we know is composed of different systems, but for the purpose of facilitating the cadaver dissection involving the limbs and the back I will only deal with two systems- 1. the Skin and the Mammary Glands 2. the Musculoskeletal Systems. Most of the other systems will be dealt with properly in other subject module.

The skin, considered to be the largest organ of the body, has a surface area a little less than 2 meter square. It is one of the best indicators of general health of an individual and, it mirrors the personality of an individual. The skin provides 1. Protection for the body from environmental effects such as abrasive trauma and other harmful substances. It also prevents fluid loss. This fluid loss prevention is best illustrated in burn patients. Depending on the degree of burn, the greater area that is involved in burn, the greater will be the fluid loss. And with the fluid loss comes the electrolyte loss. Since the skin contains millions of sensory organs, it becomes a shield against nociceptive stimuli like heat and cold, insect bites, sharp and pointed objects, etc. The skin Through the sweat glands, blood vessels, and fat deposits, the skin becomes an organ for thermoregulation. It dissipates excessive heat through the cooling effect of the sweat which is secreted by the sweat glands. It also conserve heat by the heat retaining property of the subcutaneous fats. Underneath the skin are the vital tissues and organs which, when expose to the external environment, will not survive. In severe open fractures, when there is so much skin loss, the exposed bone becomes a surgical management problem. The exposed bone cannot withstand the dessicating effect of the external environment and the risk of infection. The skin, therefore, functions as an important organ for the containment of tissues and vital organs.

Above is a picture of a severe open fracture type III involving the left ankle. Take note the discoloration of the exposed tissues. This discoloration is called gangrene and it due to loss of blood supply to the tissues coupled with the drying effect of the external environment and the presence of infection.

Above picture shows a mangled left hand due to a motorcycle accident. Note the extensive area of skin loss leaving an area of exposed tendon, open fracture of the 5th metacarpal. The wound is contaminated heavily by foreign body contaminants.

The skin consists of 2 layers- a superficial layer called Epidermis; a deeper basal layer called the Dermis. The Epidermis is a keratinized stratified (layered) epithelium with a tough outer layer composed of a fibrous protein called Keratin. The outer layer of the epidermis is continuously “shed” or rubbed away with replacement of new cells from the dermis. This process of shedding renews the epidermis of the entire body every 25-45 days. The epidermis is avascular(no blood vessels or lymphatics) and is nourished by the blood vessels in the underlying dermis. The skin is supplied by afferent nerve endings that are sensitive to touch, irritation(pain), and temperature. Most nerve terminals are found in the dermis, but few penetrate the epidermis. The dermis is formed by a dense layer of interlacing collagen and elastic fibers. These fibers provide skin tone and account for the strength and toughness of the skin. The pattern of the collagen fibers in a particular region determines the characteristic tension lines (cleavage lines of Langers) and wrinkle lines in the skin. The deep layer of the dermis contains hair follicles, with the associated smooth arrector (L. arrector pili) muscles and sebaceous glands. Contraction of the arrector muscles erect the hairs (causing goose bumps), thereby compressing the sebaceous glands and helping them secrete their oily product onto the skin. Other integumentary structures include the hair, nails, mammary glands, and the enamel of the teeth.

Underneath the dermis layer of the skin are different layers of tissue planes known as the FASCIAL LAYERS. These layers are composed of loose, irregularly arranged connective tissue composed of fibroblasts, collagen bundles, and some elastic fibers. The fibroblasts cells secrete tropocollagen, which aggregates into liquid-crystalline collagen bundles. The elasticity of the collagen found in the fascia permits adjacent muscles to shorten(contract) and lengthen independently while sliding past each other.

The above slide is a cross section of the middle leg showing the subcutaneous tissues, the deep fascia investing the muscles, bone(tibia and fibula) and the neurovascular bundles.

The subcutaneous tissue (superficial fascia) underlies the integument. This layer is relatively mobile in most region of the body with the exception of the palm of the hand and sole of the foot. The Subcutaneous tissue is composed of two distinct layers and are found between the dermis and the deep(investing) fascia. These 2 layers are the Superficial layer and the Deep layer

The superficial layer of SUBCUTANEOUS TISSUE (which is the superficial fascia) t is composed of loose connective tissue and fat. It is predominantly fatty and contains the deepest parts of the sweat glands, the blood and lymphatic vessels, and the cutaneous nerves that are distributed to the skin. It is known as the CAMPER’S FASCIA in the region of the thorax and the abdomen; CRUVEILHIER’S FASCIA in the perineum. The subcutaneous tissue provides for most of the body’s fat storage, so its thickness varies greatly, depending on nutritional state, genotype, phenotype, and location. It is particularly sensitive to estrogenic hormones. In the abdomen of overweight persons, it forms the PANNICULUS ADIPOSUS. The SKIN LIGAMENTS(retinacula cutis), consisting of numerous small fibrous bands, extend through the subcutaneous tissue and attach the deep surface of the dermis to the underlying deep fascia. The length and density of these ligaments determine the mobility of the skin over deep structures. Since this layer of superficial fascia is basically fatty, it does not hold sutures during wound closure involving the subcutaneous tissue.

The deep layer of the Superficial Fascia(or Subcutaneous Tissue) is a thin membranous layer made up of collagen. It is strong enough to hold surgical sutures during skin closures. In the thorax and abdomen, it is known as SCARPA’S FASCIA; in the perineum it is called COLLE’S FASCIA. This layer fuses with the Deep investing fascia

The Deep Investing Fascia is a dense, organized connective tissue layer, devoid of fat, that envelopes most of the body deep to the skin and subcutaneous tissues. It defines the fascial planes between muscles and, this layer cannot be stripped completely from the structures that it invests(i.e. it becomes continuous with the periosteum, perichondrium, perineurium, perimysium and other adventitial layers). With the aid of extracellular fluid, this tissue provides nearly frictionless surfaces for the motion of one muscle over another.

The Deep Investing Fascia has extensions that invest deeper structures such as individual muscles and neurovascular bundles, or, divide muscles into groups or compartments, or lie between the musculoskeletal walls and the serous membranes lining the body cavities.

Above slide at the left shows a cross section of the arm. It shows the deep fascia investing the muscles, neurovascular structures and the humeral bone at the center. The slide at the right is a cross section of the forearm where the deep investing fascia encloses every muscles, the radial and ulnar bones, the neurovascular structures. It also divides the forearm into several compartments by forming the interosseous membrane between the radius and the ulna.

The deep investing fascia also forms specialized structures like: 1. Retinacula which are strong fascial bands in the regions of joints that prevent tendons from “bow-stringing” away from the joint. 2. Bursae are fluid-filled cavities between or within fascial planes that reduce friction between tendons, muscles, ligaments, and bones. 3. Synovial tendon Sheaths are fluid-filled tunnels about the muscle tendons that permit considerable movement and reduce friction.

The above slides show the palmar view of the hand at the left side and the dorsal (or posterior) view of the hand and wrist. At the palmar side, note the synovial sheaths investing the flexor tendons. At the dorsal aspect of the hand and wrist the extensor tendons together with the extensor synovial sheath are invested by a flat fibrous bands that compartmentalize the extensor tendons. Retinacula are strong fascial bands in the region of the joints that prevent tendons from “bow-stringing” away from the joint. Synovial tendon sheaths are fluid-filled tunnels about the muscle tendons that permit considerable movement and reduce friction.

The slides above show the structure called BURSA. Bursae are sac-like structures or, cavities, filled with fluid and are interposed between tendons, muscles, ligaments and the bony surface. Bursa prevents friction as the tendon, muscles, ligaments move, or glide, against the bony surface. Bursae are considered as a special extension of the deep investing fascia.

Fascial planes (interfascial and intrafascial) are potential spaces between adjacent facias or fascia-lined structures. These potential spaces are more often seen in living people and not in cadavers where these spaces are fused. Fascial planes are important surgical access to the deeper structures.

Above slide is a cross section of the trunk at the level of the abdomen anteriorly and at the level of vertebral column between L2 and L3. It shows the abdominal wall muscles anteriorly, the abdominal cavity and its contents, the posterior abdominal wall showing the massive muscles of the back and the vertebral column and the spinal cord.

The above slide at the left side is a cross section of the trunk at the level of the abdomen. It shows the anterior abdominal wall and the posterior abdominal wall as indicated by the presence of the vertebral column. At the right side, is the cross section of the anterior abdominal wall showing the arrangement of the abdominal muscles and the fascial planes. In abdominal surgery like exploratory laparotomy where the surgeon wants to access the intraabdominal structures like the small intestines, the colon, liver, appendix the surgical incision usually passes through the middle cutting through the LINEA ALBA in between the rectus abdominis muscles.

CLEAVAGE LINES, or skin creases, represent the prevailing directionality of the connective tissue bundles and, are very important in surgical consideration, i.e., where to place the surgical incisions. The meshwork of collagen fibers (elastic fibers to some extent) provides overall mobility of the skin. Although microscopically, the connective tissue fibers in the dermis appear randomly oriented, there is a prevailing direction in each area of the body, denoted by the crease, or Langer’s lines. The elasticity of the collagen fibers create a slight tension. When connective tissue fibers are severed, they retract so that wounds gape. Incision made across Langer’s lines retract considerably, resulting in gaping wounds and prominent scar formation. incision made parallel to Langer’s lines sever fewer connective tissue fibers thereby decreasing the tendency to retract and resulting less unsightly scar.

The above slides shows the direction of the skin wrinkles(or skin cleavage lines of Langers) in relation to the direction of the muscles. The cleavage lines in the face are usually oriented transverse to the orientation of the muscles.

The above slide shows the breast and the areola and nipple complex. The cleavage lines of Langers around the breast follow a circular pattern that is most prominent toward the areola and nipple complex.

The cleavage lines of Langer follow different pattern in different anatomic regions. In the chest(thorax), base of the neck and abdomen, the cleavage lines tend to be circumferential. For the female breast, the cleavage lines tend to be circumferential to the nipple. In the joints, the cleavage lines tend to be circumferential. In surgical procedure involving the female breast, the surgical incision is usually circumferential and placed around the areolar margin for cosmetic reason.

The innervation of the skin is segmental in pattern. This segmental innervation has an embryonic origin. All chordates (that includes the humans) exhibit somatic segmentation, or, metamerism. This segmentation is retained and exhibited in the human body particularly the spine. Between each two vertebrae, a left and right mixed(afferent plus efferent) spinal nerve arises to supply a dermatome and a myotome. A dermatome is a discrete region of skin of the body wall or limb that originates from a segment. A myotome is a discrete group of muscles of the body wall or limb that originates from a segment. The superficial branches of each spinal nerve terminate in nerve endings of corresponding dermatomes.

The above slide shows the segmental innervation of the neck and upper extremity. The different colored segments of the skin represent the dermatome that is innervated by the corresponding spinal nerve. Example, the side of the neck extending from the ear to the upper 1/3rd of the neck is a dermatome innervated by spinal nerve C1. The inner side (medial side) of the arm is innervated by spinal nerve T1

Knowing the cleavage lines of Langers is important in understanding the placement of surgical skin incisions. A skin incision placed across the Langer’s lines result in a gaping wound and formation of prominent scar. On the other hand, placing the skin incision parallel to the Langer’s line results in less unsightly scar because few connective tissue fibers are cut thereby decreasing the tendency to retract. In breast surgery be it a tumor surgery, or, a cosmetic surgery, most of the skin incision is semicircular in pattern and is placed at the margin of the areola since the Langer’s lines in this particular breast area are circular towards the areola and the nipple. In surgery involving the neck area like thyroid removal, the skin incision follows the neck skin creases. In surgery involving the extremities, most of the surgical skin incisions are longitudinal since the Langer’s lines follow longitudinal pattern. In surgery of the hand at the palmar aspect, the skin incision are placed 45 degrees in relation to the palm and digit skin creases. Oftentimes, if longer skin incision is necessary a zigzag skin incision is the usual pattern.

The wrinkle lines of the face as shown above represent the cleavage lines (Langer’s lines). The direction of the skin wrinkles is transverse to the direction of the facial muscles. However, the skin wrinkles(or cleavage lines of Langers) represent the direction of the connective tissue fibers of the skin.

There are several conditions in which the skin becomes an extension of disorders not directly involving the skin per se but conditions away from the skin. Traumatic injury involving the spinal cord is manifested externally by a particular pattern of sensation loss in certain area of the skin known as the dermatome. Peripheral nerve injury in form of trauma or peripheral nerve entrapment is also manifested by loss of skin sensation that is innervated by the injured nerve. Reference landmarks include the nipple and the umbilicus, which are in the 4th thoracic and the 10th thoracic dermatomes, respectively Stretch skin marks are common during pregnancy. The collagen and elastic fibers in the dermis form a tough flexible meshwork of tissue. The skin can distend considerably when the abdomen enlarges, as in pregnancy or in obese individual. However, if stretched too far, it can result in damage to the collagen fibers in the dermis. Bands of thin, wrinkled skin, initially colored red, becoming purple and later white appear on the abdomen, buttocks, thighs, and breast. Stretch skin marks generally fade but never disappear completely after pregnancy and weight loss.

One of the clinical conditions that one can see in clinical situation is BURNS. Depending on the degree or the area of the skin that is affected, it is a reminder of how important the skin is. It is a therapeutic and management problem in terms of wound care, electrolyte and fluid balance, infection control, scar formation. Burns are classified into the following: a. First-degree burns, the damage is limited to the superficial part of the epidermis. Healing is usually nonproblematic and functional impairment is almost nil. b. Second-degree burns, the damage extents through the epidermis into the superficial part of the dermis. However, except for their most superficial parts, the sweat glands and hair follicles are not damage and can provide the source of replacement cells for the basal layer of the epidermis. c. Third-degree burns, the entire epidermis, dermis and perhaps the underlying muscles are damaged. A minor degree of healing may occur at the edges, but open ulcerated portions require skin grafting. The extent of burn (per cent of total body surface affected) is more significant than the degree(severity of depth) in estimating its effect on the victim. In terms of long term complication of burns the severity of depth as well as the per cent of total body surface affected become important factor. Ulcerated portions seen in third-degree burn usually heal by scarification. The scar formation will affect the mobility of the affected part. If the joints are affected, contracture becomes a problem. PHYSICAL THERAPY becomes the mainstay in the long term management of contracture.

The skin serves as a mirror for several medical conditions ranging from liver diseases to viral infections to hemodynamic abnormalities. Jaundice(yellowish discoloration) of the skin is associated with liver diseases. Viral Infections like Dengue, measles and herpes zoster are classically diagnosed by their cutaneous manifestations in addition to their myriad of signs and symptoms. Hemodynamic abnormalities like chronic blood loss secondary to slow bleeding peptic ulcer, gastrointestinal parasitic (helminthic) infection, neoplastic diseases, is manifested in the skin as pallor. Acute blood loss due to trauma is manifested through the skin as pallor due to vasoconstriction associated with cold and clammy skin. Skin diseases like fungal infections(tinea), eczematous reaction to allergens, are all manifested by skin.

Among diabetics, the skin is often the site of ulcer formation due to vascular as well as neurologic insufficiency. These processes of vascular insufficiency as well as peripheral neuropathy are shown more in its cutaneous manifestations. It usually affects the distal part of the extremities specially the foot. These ulcers are basically ischemic in character due to chronic lack of O2 delivery to the lower extremities due to clogged arteries. These diabetic ulcers are aggravated by secondary bacterial infection.

The above slide shows the different cutaneous colors of the digits due to the difference in blood supply. This lesion is generally called diabetic foot since it is a very common lesion among diabetics. The lesions in diabetic foot vary in gross and clinical manifestations. It ranges from simple skin blisters, to diabetic skin ulcers, to frank gangrene that may involve only a digit, or, several digits; or, the whole forefoot to the entire foot to the entire leg of extremity. In this slide the big toe is blackish in color which is obviously gangrenous. The 2nd digit is grayish in color and later, will be like the big toe. The 3rd to the 5th toes are pinkish in color indicating good better vascular status, that is, the blood flow to these 3 digits is still intact.

Above slide shows a deep cutaneous ulcer at the medial aspect of the first metatarsophalangeal joint. Probing the ulcer will lead to the joint indicating that the septic process had reach the joint and, due to the increased joint pressure exerted by the product of inflammation like the pus, the skin beside the joint rupture creating the skin ulcer.

The above slide shows another form or variant of a diabetic foot in which the whole 4th digit and a part of the 3rd digit are lost due to the combination of loss of blood supply and infection. It leaves a huge skin crater involving the plantar aspect of the foot.

This slide shows the dorsal involvement of the same foot as soon previously. Note the extent of the skin ulceration.

One of the medical conditions that can be diagnosed by a cutaneous lesion is the Systemic Lupus Erythematosus. Although not all patients will have this cutaneous lesion, one can be sure of the diagnosis if this lesion become very apparent.

In retrospect, the skin is a very important organ. In terms of business, the skin has been the most commercialized organ of the body. Products ranging from shampoo, soap, lotion, make-ups, etc., are all advertised as skin friendly. Beautiful is synonymous to a beautiful skin. The skin also serves as one of the best indicators of health. Abnormal skin pallor creates a host of different medical conditions. A yellowish discoloration of the skin called jaundice points to the different conditions affecting the liver and other parts of the Biliary System. Finally, cutaneous lesions as shown by the previous slides are, perhaps, the nature’s way of warning the clinician that more serious underlying diseases should be considered.

Both male and female have breasts ( L. mammae); normally the mammary glands are well developed only in women and are accessory to reproduction. In men these are functionless and consisting of only a few small ducts and cord. The mammary glands are modified sweat glands and therefore have no special capsule or sheath that envelopes them. The contour and volume of the female breast in nonpregnant state is produced by the subcutaneous fat. During pregnancy the mammary glands enlarged and new glandular tissue forms. During puberty (age 8-15 yrs), the female breasts normally grow because of glandular development and increased fat deposition. Breast size and shape result from genetic, racial and dietary factors

The breasts are the most prominent surface features of the anterior chest wall , especially in women. Their flattened superior surface show no sharp demarcation from the anterior surface of the thoracic wall. However, laterally and inferiorly the borders are well defined. The cleavage in the anterior median line- the INTERMAMMARY CLEFT- is between the breast. The NIPPLE which almost in line with the midclavicular line is surrounded by slightly raised and circular pigmented area- the AREOLA. The color of the areola vary with the woman’s complexion; they darken during pregnancy and retain this color thereafter.

Between the breast and the deep pectoral fascia is a loose connective tissue plane or potential space- the retromammary space (bursa). This plane, containing small amount of fat, allows the breast some degree of movement on the deep pectoral fascia. The mammary gland is firmly attached to the dermis of the overlying skin by the suspensory ligament (of Cooper). These ligaments, particularly well-developed in the superior part of the gland, help support the mammary gland lobules. The greatest prominence of the gland is the nipple and which is surrounded by a circular pigmented area (the areola). The breast contains 15-20 lobules of glandular tissue which constitute the parenchyma of the gland. The breast contains 15-20 lobules of glandular tissue, which constitute the parenchyma of the gland. Each lobule is drained by a lactiferous duct, which opens independently on the nipple. Just deep to the areola, each duct has a dilated portion- the lactiferous sinus.

The arterial supply of the breast comes from the arterial branches of the following main arteries: 1. Subclavian artery 2. Axillary artery 3. thoracic artery. From the subclavian artery, the branches are the Internal thoracic artery which gives rise to the medial mammary branches of the perforating branches and the anterior intercostal branches that directly the medial side of the breast. From the AXILLARY ARTERY comes the lateral thoracic and the thoracoacromial arteries which supply the lateral side of the breast. From the thoracic aorta are the posterior intercostal arteries that supply the pectoral side of the breast.

The main venous drainage of the breast is to the axillary vein but some medial part of the breast drain to the internal thoracic vein.

The lymphatic drainage of the breast is important because of its role in the metastatic spread of breast cancer cells. Lymph passes from the nipple, areola, and lobules of the gland to the subareolar lymphatic plexus. Most lymph (>75%), especially coming from the lateral quadrants of the breast, drains to the AXILLARY LYMPH NODES (composed of the pectoral, humeral, subscapular, central and apical nodes). Initially the lymph drains for the most part to the pectoral (anterior) nodes. However, some lymph may drain directly to other axillary nodes, or to interpectoral, deltopectoral, supraclavicular, or inferior deep cervical nodes.

Most of the remaining lymph, particularly from the medial breast quadrants, drains to the parasternal lymph nodes or to the opposite breast. Lymph from the inferior breast quadrants may pass deeply to abdominal lymph nodes (inferior phrenic nodes). Lymph from the axillary nodes drains to infraclavicular and supraclavicular nodes and from them to the subclavian lymphatic trunk. Lymph from the parasternal nodes enter the bronchomediastinal trunks, which ultimately drain to the thoracic or right lymphatic duct.

In describing and locating a lesion in the breast, it is divided into 4 quadrants by a horizontal and vertical lines that pass through the nipple at the center. The axillary tail of the mammary gland is located at the upper outer quadrant.

In evaluating patient for a breast mass, the patient is made to sit with both her hands behind her head. The breast should be inspected for asymmetry, dimpling of the skin, erythema or edema. Each breast should then be carefully palpated from the clavicle to below the inframammary fold and from the sternum to the posterior axillary line, with pains taken to include the subareolar area. If an abnormal area is identified, its size, contour, texture, tenderness, and position should be described. A diagram of the lesion is extremely useful for future reference. Next the nipple and the areolae are inspected for skin breakdown and squeezed gently for check for discharge. The number and position of any ducts from which the discharge is obtained should be recorded, and the color of the discharge (milky, green, yellow, clear, brown , or bloody) and its consistency (watery, sticky, or thick) should be noted. Discharge on one side calls for a search on the other side because unilateral, single-duct discharge is much more suspicious for malignancy than bilateral, multiple-duct discharge. For routine self breast examination, it is best done lying down. The hand, at the side of the breast to be examined, is placed at the back of the neck. This position tenses the pectoral fascia and elevates the lower part of the breast and making it accessible to palpation. Start palpating the upper inner quadrant then the lower inner quadrant to the lower outer quadrant then the upper outer quadrant. Palpation should extend to cover the axillary tail of the breast. In describing a breast lesion note the following: 1. location- what quadrant is the mass located? 2. Size- estimate it and compare it with the size of a familiar object like a corn kernel, size of a coin (1-centavo, 25-centavo, 1 peso coin) 3. Mobility- Is the mass movable or fixed? 4. tenderness- Is the mass painful on palpation? Also observe for the following signs: 1. inflammatory signs- redness, swelling, increased warmth of the overlying skin 2. Presence of skin ulceration 3. Nipple discharges 4. Orange peel appearance of the overlying skin Finally, the axillary and supraclavicular nodes in both sides should be examined. If enlarged nodes are palpated, their size, mobility, tenderness, and number should be recorded.

Breast biopsy is a surgical procedure in which a piece of tissue from a breast mass or lump is taken for histopathological studies- that is, to determined microscopically if the lesion is benign or malignant. Biopsy can be done either by closed method or open method. Closed method uses hypodermic needle that is inserted into the breast lesion under local anesthesia and with constant suction applied on the syringe the needle is moved back and forth until tissue samples are aspirated. Fine needle biopsy and core-needle biopsy are essentially the same except that the latter uses a bigger bore needle. Fine needle biopsy if done by an expert operator could be accurate enough for diagnosis. It is also cheap since it could be done in the doctor’s clinic and only requires local anesthesia or sedation. It does not require an OR setting. However, since the tissue sample taken from the breast tissue may not be enough or, it may not represent the lesion, sampling error could be a problem. Open biopsy, on the other hand, is more accurate since an ample tissue sample can be taken under direct vision. However, the danger of seeding the cancer cells is also greater. Most of the breast mass biopsy is done using fine needle biopsy.

Surgical skin incision depends on the size, location, and nature of the mass. For small benign lesion a small curvilinear incision following the Langers cleavage lines are used. If the lesion is located near the areola or the nipple, a periareolar skin incision is preferred

Surgical procedures to remove breast cancer have undergone a lot of changes. What use to be mutilating procedures before, most surgeries are now breast tissue conserving procedures. With the advent of chemotherapy and modern techniques of tracing breast cancer cells, survival rate of breast cancer patients is increasing.

The skeletal system is the framework of the body and is composed of bones and cartilages. It has 2 main parts- the axial skeleton and the appendicular skeleton

The bony tissue that makes up the skeletal system is a living tissue that is capable of renewing by itself. It is one of the tissues that is capable of healing to its original form of tissue when it is damaged or injured. Comparing to other tissues like the skin, muscles, nerves, brain, that heal by fibrosis when injured or damaged, bony tissue regenerates to its original form. If properly managed fractured bones heal to its original bony architecture. It is also a fact that only bone can stimulate an injured bone to heal. A protein called the Bone Morphogenetic protein that is only found in the bony tissue can stimulated osteogenesis (that is, induce progenitor cells to become bone cells). This is the principle in bone grafting. Bony tissue needs constant blood for nourishment. It undergoes necrosis once deprived of blood. It is a highly specialized tissue for weight bearing; for leverage upon which muscles attached; for hematopoiesis for continuous supply of new blood cells; and for storage of calcium which is important in metabolic activities of other tissues like the muscles.

The axial skeleton consists of the bones of the head and face, vertebral column (cervical, thoracic and lumbar vertebrae), and the thoracic cage(rib and sternum). The appendicular skeleton is composed of the bones from the upper limb, shoulder girdle, pelvic girdle, and the lower limbs.

There are 2 types of bone: compact and spongy (trabecular or cancellous). The differences between these types of bone depend on the relative amount of solid matter and the number and size of the spaces they contain. All bone have a superficial thin layer of compact bone around a central mass of spongy bone, except where the latter is replaced by a medullary (marrow) cavity. The architecture of spongy and compact bone varies according to function. Compact bone provides strength for weight bearing. In long bones, designed for weight bearing and attachment of muscles and ligaments, the amount of compact bone is greatest near the middle of the shaft. Most of the spongy bones are located at both ends of a long bone at the metaphyses and epiphyseal parts where it articulates with another bone to form a joint. Note that the ends are flared and bulbous in structure. These parts play important role in weight dissipation and weight transfer to the other side of the joint.

Cartilage is a resilient, semirigid connective tissue that are found in some parts of the skeleton where flexibility is needed. Example are the costal cartilages that attach the ribs to the sternum. The thoracic cage is in constant motion-that is, chest expansion and contraction, during respiration. The costal cartilage are placed in this anatomical position for greater flexibility of the thoracic cage. In the joints like the glenohumeral and the knee joints, the articulating surfaces of bones participating in a synovial joint are capped with articular cartilage, which provides smooth, low friction gliding surfaces for free movement of the articulating bones. The cartilage is devoid of blood supply (avascular), and is, therefore, nourished by diffusion of joint synovial fluid. It is also alymphatic, that is, without any lymphatic drainage. It is also aneural, that is, without nerves. The proportion of bone and cartilage in the skeleton changes the body grows. In the newborn infant, its skeleton is mostly composed of cartilage. In adult, the cartilaginous parts are confined to the joints and to the parts of the body where flexibility is needed.

The above slide above shows part of the thoracic cage where the costal cartilages that are attached to the sternum to give elasticity and resiliency to the thoracic cage.

The proportion of bone and cartilage in the skeleton changes as the body grows; the younger a person is, the greater the contribution of cartilage. In the radiograph of foot at birth as shown above, note the radiolucent areas at the midfoot and at the metatarsophalangeal joint area. This radiolucent areas represent the cartilaginous part of the foot. Since cartilage has the density of water, it appear as radiolucent area. The radiodense part of the foot are bony structures

During infancy when most of the skeletal system are cartilaginous, the skeletal system can be manipulated to different position. In the example of the deformity known as talipes equinovarus (or, clubfoot deformity), the foot can be manipulated to a normal position in a gradual fashion. The process is called serial casting. The foot is gently manipulated to its normal position and maintained by a long leg circular cast. This manipulated is repeated every week for as long as 6 months.

The above slides show the same foot as shown previously. Note the correction of the clubfoot deformity after just 1 month of serial casting. Operative procedures to correct the bony deformity in this stage of infancy is forbidden because it will result in a very small and shorten foot.

As the child grows older the cartilaginous parts are confined at the epiphyseal plates, or growth plates, of the bones.

The fibrous connective tissue covering that surrounds the bone is called PERIOSTEUM; that surrounding cartilage elements, excluding the articular cartilage, is called PERICHONDRIUM. The periosteum and perichondrium help nourish the tissue; are capable of laying down more cartilage or bone (particularly during fracture healing), and provide an interface for attachment of tendons and ligaments.

The bone, being a living tissue, is richly supplied with arterial vessels. However, compared to arterial supply of other tissues like the muscle, the number of arterial blood vessels per square cms. is much less in bone. Two thirds of the inner portion of the bone is supplied by the nutrient artery that penetrates the bone through the nutrient foramen. It enters the medullary cavity and branches out throughout the length of the medullary cavity. The nutrient artery is usually accompanied by a vein. The outer one third of the bone is supplied by the arteries coming from the periosteum. The proximal and distal part of the bone is supplied by the metaphyseal and epiphyseal arteries.

The blood supply to the bone influences the way treatment of bone fractures. The slide above is an open fracture type III. It is a severe type of fracture with so much soft tissue damage and wound contamination. Note the severe laceration of the skin and the damage to the muscles and other soft tissues like the periosteum and fascial tissues.

The xray film of the tibia and fibula of the leg of same patient. Note the big fracture fragment. Bone comminution is a sign that a force of greater magnitude causes the fracture. Bone comminution is usually associated with soft tissue (muscle, periosteum) injuries.

The picture is the superior view of the fracture site showing the distal tibial fragment contaminated with foreign bodies.

The woman was treated with debridement (removal of devitalized tissues and foreign bodies contaminating the wound. The fracture fragments were then realigned (or, reduced) and the alignment was maintained by an external fixator assembly. The wound was allowed to heal by secondary intention- that is, no immediate wound closure by suturing. The wound was left unsutured; let the wound granulate and later, wound was covered by a scar tissue.

A JOINT is an articulation, or the place of union or junction between 2 or more rigid components. It may be between 2 bones, or between 2 cartilaginous surfaces, or, even parts of same bone. It function as a pivot point for rotation of a bone on another bone. It also serves as transference and dissipation of forces coming from muscle action, gravity and weight acting on the body or part of a body.

The study of the classification, structure and function of the joints is called ARTHROLOGY. It is the anatomic basis and foundation of KINESIOLOGY which is the discipline that deals with joint motion. The structure and function of a joint changes with age. Other factors like disease and long term immobilization are also factors affecting the structure and function of joints.

The composition , proportion, and arrangement of biologic materials that compose the connective tissue within joints influence the mechanical performance of joints. These biologic materials are the fibers, ground substance and the cells. These biologic materials are blended in various proportions based on the mechanical demands of the joint

The fibers that composed the joint are the collagen and the elastin fibers. The collagen fibers make up the greater proportion. Collagen fibers are made of short subunits (or fibrils) which are wound in a helical structure much like short threads. These threads are placed together in a strand. Several strands are then spirally wound into a rope. In normal joints, although there are 12 collagen types that are identified only 2 are predominant collagen fibers- Type I and Type II collagen fibers. Type I collagen fibers are thick, rugged bundled fibers that elongate very little when place under tension. Being relatively stiff, type I collagen fibers are ideal for binding and supporting articulations between bones. Type I collagen fibers is, therefore, the primary protein found in ligaments and fibrous joint capsules. It is also the biologic material found in tendons- the structures that transmit the force of muscle to the bone.

A. The bundles of collagen in a tendon are tightly packed and arranged parallel to one another. The arrangement allows the tendon to transmit unidirectional tensile forces from the muscle to take up slack in the bundles. The cells that maintain this connective tissue (fibrocytes) are few in number and flattened between the collagen bundles. B. A ligament has collagen bundle that are less parallel to one another. This allows to accept tensile forces from several directions while holding the bone together.

Type II collagen fibers are thinner than type I and possess slightly less tensile strength although this type of fiber still provides internal strength to the tissue in which it resides. These fibers provide a flexible woven framework for maintaining general shape and consistency of more complex structures such as the hyaline cartilage.

In addition to collagen, the connective tissues within the joints have varying amounts of elastin fibers. These fibers are composed of netlike interweaving of small elastin fibrils that resist tensile (stretching) forces, but they have more of “give” than elongated. Tissues with a high content of elastin readily return to their original shape after being deformed. This property is useful in structures that undergo significant deformation like in certain spinal ligaments and in cartilage of the ear and nose, that help return a bone to its original position after movement.

Collagen and elastin fibers are embedded within a water-saturated matrix known as ground substance. The ground substance of joint tissues is made of glycosaminoglycans (GAG), water, and solutes. The GAGs are highly branched and negatively charged amino sugars that are strongly bonded with water. Structurally, the GAGs resemble long bottle brushes that are strongly hydrophilic due to their negative charges. Water provides a medium for diffusion of nutrients within a tissue. In addition, water assists with the mechanical properties of tissue. The tendency of GAGs to imbibe and hold water causes the tissue to swell. Swelling is limited by embedded collagen or elastin fibers anchored into an adjacent, supporting structures, such as bone or dense bands of fibers. The interaction between the restraining fibers and the swelling GAGs provides a turgid structure that resists compression, much like a balloon or water of filled mattress. Such an example of such a structurally dynamic material is ARTICULAR CARTILAGE. This important tissue provides an ideal surface covering for joints and is capable of dispersing the millions of repetitive forces that have an impact on joints throughout a lifetime.

The cells within connective tissues of the joints are responsible for maintenance and repair. In contrast to skeletal muscles, these cells do not confer significant mechanical properties on the tissue. Damaged or aged components are removed, and new components are manufactured and remodeled. Cells of connective tissues of joints are generally sparse and interspersed between strands of fibers or embedded deeply in regions of high GAG content. This sparseness of cells in conjunction with limited blood supply often results in poor or incomplete healing of damaged or injured joint tissues.

Dense irregular connective tissue is found in the fibrous external layer of articular capsule and ligaments. Structurally, it has high proportion of type I collagen fibers that are arranged in bundles and aligned to resist the natural stresses placed on the tissues. The connective tissue bundles function most effectively when these are stretched parallel to their long axis. After their initial slack is pulled tight, the ligaments and joint capsule provide immediate tension that restrains undesirable motion between bony partners. The fibrous joint capsule and ligaments resist forces from several directions. To accomplish this, the fiber bundles within the connective tissues are arranged in several dominant directions, unlike the parallel bundles found in a tendon. The GaGs and elastin fibers are usually low in dense irregular connective tissue.

Articular cartilage is a specialized type of hyaline cartilage that forms the load bearing surface of joints. It has a thickness that ranges from 1mm to 4mm in areas of low compression force and 5-7mm in areas of high compression. The tissue is avascular(that is, no blood vessel) and aneural (no nerve). Unlike regular hyaline cartilage, articular cartilage lacks a perichondrium which is a connective tissue that covers most cartilage. The absence of perichondrium on the surface of the cartilage makes the cartilage ideal for load-bearing surface. Since the perichondrium contains blood vessels and a ready supply of primitive cells that maintain and repair underlying tissue, the lack of it in articular cartilage is really a disadvantage. Even though articular cartilage is capable of normal maintenance and replenishment of its matrix, significant damage to adult articular cartilage is often repaired poorly or not at all.

Chondrocytes of various shapes are located within the ground substance of different layers or zones of articular cartilage. These cells are bathed and nourished by nutrients within the synovial fluid. Nourishment is facilitated by the “milking” action of articular surface deformation during intermittent loading. The chondrocytes are surrounded by predominantly type II collagen fibers. The fibers are arranged to form a retraining network or “scaffolding” that adds structural stability to the tissue. These series of chemically interlinked fibers form a netlike fibrous structure that entraps the large GAG molecules beneath the articular surface. The GAG in turn attract water that provides rigidity to the articular cartilage. The rigidity increases the ability of cartilage to withstand loads. The articular cartilage distributes and disperses compressive forces to the subchondral bone. It also reduces friction between two surfaces. The coefficient of friction between two surfaces covered by articular cartilage and wet by synovial fluid is extremely low. In the human knee the coefficient of friction is in the range of 0.005 to 0.02. This is 5 to 20 times more slippery than ice on ice, which has a coefficient of friction of 0.01.

As its name implies, fibrocartilage has a much higher fiber content that other types of cartilage. The tissue functionally shares properties of both dense irregular connective tissues and articular cartilage. It is composed of dense bundles of type I collagen fiber that are oriented in different directions with moderate amount of GAGs. Rounds of chondrocytes reside within lacunae that are embedded within a dense collagen network.

The dense interwoven collagen fibers allow the tissue to resist tensile and shearing forces in multiple planes. Fibrocartilage is therefore an ideal shock absorber in regions of the body that are subjected to high multidirectional forces. These regions are the knee, the hip, and vertebral column. While the fibrocartilage has a surrounding perichondrium, it is poorly organized and contains small blood vessels located only near the peripheral rim of the tissue. Fibrocartilage is aneural and thus does not produce pain or participate in proprioception, although a few neural receptors may be found at the periphery where fibrocartilage abuts a ligament or joint capsule. The nourishment of the adult fibrocartilage is largely dependent on diffusion of nutrients through the synovial fluid in synovial joints. In amphiarthrodial joints , such as the adult intervertebral disc, the nutrients are diffused across the fluid contained in the adjacent trabecular bone. The diffusion of nutrients and removal of metabolic wastes in the fibrocartilage of amphiarthrodial joints is assisted by the “milking” action of intermittent weight bearing.

The meniscus partially dissipates the compression force by spreading out in radial direction as indicated by the arrows. A histologic picture of the meniscus shows the chondrocytes are flattened in shape and is oriented parallel to the compressive force.

Bone provides rigid support to the body and equips muscles of the body with a system of levers. The outer cortex of the long bones of adult skeleton has a shaft composed of thick, compact cortical bone. The ends of the long bones, however, are lined with a thin shell of compact bone that covers an interconnecting network of cancellous bone. Bones of the adult axial skeleton, such as the vertebral body, possess an outer shell of cortical bone that is filled with a supporting core of cancellous bone.

The structural subunit of cortical bone is the OSTEON, or HAVERSIAN system, which organizes the collagen fibers, predominantly type I, into a unique series of concentric spirals that form lamellae. The matrix of bone contains calcium phosphate crystals, which allow bone to accept tremendous compressive loads. The cells of bone are confined within narrow lacunae (i.e. spaces) positioned between the lamellae of the osteons. Because bone deforms very little, blood vessels can pass into its substance from the outer periosteal and the inner endosteal surfaces. The vessels can then turn to travel along the long axis of the bone in a tunnel at the center of the haversian canal. The connective tissue of the periosteum and endosteum are richly vascular and are innervated with sensory receptors for pressure and pain.

Bone demonstrates its greatest strength when compressed along the long axis of its shaft, which is comparable to loading a straw along its long axis. The ends of long bone receive multidirectional compressive forces through the weight-bearing surfaces of articular cartilages. Stresses are spread to the adjacent subchondral bone and then into the network of cancellous bone, which in turn acts as a series of struts to redirect the forces into the long axis of the cortical bone of the shaft. This structural arrangement redirects forces for absorption and transmission by taking advantage of bone’s unique architectural design.

Joints are classified according to the anatomic structure and the movement potential. The anatomic structure includes the types of connective tissues that form the structure of the joints. the Based on these, joints are classified into 3 types- 1. SYNARTHROSIS 2. AMPHIARHROSIS 3. DIARTHROSIS or Synovial joint The SYNARTHROSIS are united by the dense irregular connective tissues. The amount of movement occurring at a fibrous joint depends in most cases on the length of the fibrous fibers uniting the articular bones. This relatively rigid junction allows little or no movement at all. A syndesmosis is a type of fibrous joint in which the bones are united with a sheet of fibrous tissue, either an ligament or fibrous membrane. Consequently, this type of joint is partially movable. A GOMPHOSIS (dentoalveolar syndesmosis) is a type of fibrous joint in which a peg-like fibrous process stabilizes a tooth and provides proprioceptive information (e.g., about how hard we are chewing or clenching our teeth). The function of SYNARTHROSIS is to bind bones together and to transmit force from one bone to the next with minimal joint motion. A SYNARTHROSIS allows forces to be dispersed across a relatively large area of contact

An AMPHIARTHROSIS joint is a junction between bones that is formed primarily by fibrocartilage and/or hyaline cartilage. The best example of this joint is the intervertebral disc of the spine. The intervertebral disc together with the embedded nucleus pulposus provide a rugged, resilient cushion that absorbs and disperses forces between adjacent vertebrae.

The above slide shows the different joints in the skeletal system classified as fibrous joints. SUTURES of the cranium are fibrous joints in which bones are close together and united by fibrous tissue, often interlocking along the wavy line. These flat bones consist of two plates of compact bone separated by spongy bone and marrow (diploe) In SYNDESMOSIS joint, the bones are joined by a sheet of fibrous tissue as shown by the interosseus membrane joining the forearm bones. In GOMPHOSIS joint, a peg-like process fits into a socket ( e.g., the articulation between the root of the tooth and the alveolar process). Fibrous tissue , the periodontium, anchors the tooth in the socket

The epiphyseal plate of a growing skeleton is a primary cartilaginous (Synchondrosis) composed of hyaline cartilage. The epiphyseal plate binds the epiphysis with the main body of the bone.

A diarthrodial joint is an articulation that contains a fluid-filled joint cavity between bony partners. Because of the presence of synovial membrane, diarthrodial joints are more frequently referred to as synovial joints. These are the most common joints of the upper and lower extremities. Seven structures or elements are always associated with diarthrodial/synovial joints. 1. Synovial fluid which provides lubrication and nutrition. 2. Articular cartilage that covers the ends of the bones and provides smooth gliding motion between the bony partners. 3. Articular capsule which is composed of 2 histologically distinct layers. The inner layer consists of a 4. synovial membrane, which averages 3-10 cell layers thick. This membrane acts a barrier to adjacent capillaries, permitting only the fluid and the solutes of blood plasma into the synovial fluid of a normal joint. Blood cells and large proteins, such as antibodies, are normally excluded from the synovial space. The cells of the synovial membrane also manufacture and add hyaluronate and lubricating glycoprotein (Lubricin) to the joint fluid. The external, fibrous , layer of articular capsule of a synovial joint is composed of dense irregular tissue. The articular capsule provides support between the bones and provides containment of the joint contents. The outer part of the articular capsule do not have uniform thickness. Certain regions of the fibrous capsule are thicker in order to resist or control specific motions. The thickened regions of connective represent 5. capsular ligaments. Example are the collateral ligaments of the knee joint. The joint capsule is supplied with small 6. blood vessels with capillary beds that penetrate as far as the junction of the fibrous capsule and synovial membrane. 7. Sensory nerves also supply the fibrous capsule with appropriate receptors for pain and proprioception.

To accommodate the wide spectrum of joint shapes and functional demands, other elements may sometimes appear in synovial joints. INTRAARTICULAR DISC, or MENISCI, are pads of fibrocartilage imposed between the articular surfaces of the synovial joints. These structures increase articular congruency and improve force dispersion. Two large synovial joint of the body possess a peripheral labrum of fibrocartilage. The labrums of both the glenoid cavity of the glenohumeral joint and the acetabulum of the hip. These specialized structures deepen the concave member of these joints and support and thicken the attachment of the joint capsule. Fat pads are variable in size and positioned within the substance of the joint capsule, interposed between the fibrous capsule and the synovial membrane. Fat pads are most prominent in the elbow and knee joints. They thicken the joint capsule, causing the inner surface of the capsule to fell nonarticulating synovial spaces (i.e., recesses) formed by incongruent bony contours. In this sense, fat pads reduce the volume of synovial fluid necessary for proper joint function Synovial plicae (i.e., synovial folds, synovial redundancies, or synovial fringes) are slack , overlapped pleats of tissue composed the innermost layers of the joint capsule. They occur normally in joints with large capsular surface areas such as the knee and elbow. Plicae increase synovial surface area and allow full joint motion without undue tension on the synovial lining.

Because an in-depth understanding of synovial joint is so crucial to an understanding of the mechanics of movement, they are further classified using an analogy to familiar mechanical objects or shapes.

A hinge joint is analogous to the hinge of the door, formed by a central pin surrounded by large hollow cylinder. The angular motion at hinge joints occur primarily in a plane located at right angles to the hinge, or axis of rotation

A pivot joint is formed by a central pin surrounded by a larger cylinder. Unlike a hinge, the mobile member of a pivot joint is oriented parallel to the axis of rotation. This mechanical orientation produces the primary angular motion of spin, similar to a doorknob’s spin around a central axis. Two excellent examples of pivot joints are the proximal radioulnar joint and the atlantoaxial joint between the dens of the 2nd cervical vertebra and the anterior arch of the first cervical vertebra.

A ball-and-socket joint has a spherical convex surface that is paired with a cuplike socket. This joint provide motion in 3 planes. The symmetry of the curves of the two mating surfaces allows spin without dislocation. Anatomic examples are the glenohumeral joint and the hip joint.

An ellipsoid joint has one partner with a convex elongated surface in one dimension is mated with a similarly elongated concave surface on the second partner. The elliptic mating surfaces severely restrict the spin between two surfaces but allow biplanar motions, usually defined as flexion-extension and abduction-adduction. The anatomic example of this joint is the radiocarpal joint. The “flattened ball” of the convex member of the joint (i.e., carpal bones) cannot spin within the trough (i.e., distal radius) without dislocating.

A plane joint is the pairing of two flat or relatively flat surfaces. Movements combine sliding and some rotation of one partner with respect to the other- much like a book can be slid over a tabletop. Most of the intercarpal and intertarsal joints are considered plane joints. The motion in this joints are restricted by the tension generated by muscles acting on them and the ligaments.

The carpometacarpal joints of the 4th and 5th metacarpals are examples of plane joints. Joint motion at these joints consists of sliding from side to side along the long and transverse axes of the hamate bone to with the bases of the 4th and 5th metacarpals are articulated.

Each partner of a saddle joint has two surfaces: one surface is concave, and the other is convex. These surfaces are oriented at approximate right angles to one another and are reciprocally curved. The shape of the saddle joint is best visualized using the analogy of a horse’s saddle and rider. From front to back, the saddle presents a concave surface reaching from the saddle horn to the back of the saddle. From side to side, the saddle is convex stretching from one stirrup across the back of the horse to the other stirrup. The rider is also doubly curved, presenting convex and concave curves to complement the shape of the saddle. The carpometacarpal joint of the thumb is the best example of a saddle joint. The reciprocal interlocking nature of the joint allows ample biplanar motion, but limited spin between the trapezium and the first metacarpal.

A condyloid joint is much like a ball-and-socket joint except that the concave member of the joint is very shallow. Condyloid joints usually allow 2 degrees of freedom. Ligaments or bony incongruity restrain the third motion. Condyloid joints usually occur in pairs like the knees, temporomandibular joints, the atlantooccipital joints. The metacarpophalangeal joints are also condyloid joints. The root word of the term “condyle” actually means “knuckle”.

CLINICAL ANATOMY BY DANILO V. OLEGARIO M.D., FPOA SILLIMAN UNIVERSITY

CLINICAL ANATOMY INTRODUCTION - REGIONS OF THE HUMAN BODY TO BE COVERED BY THIS MODULE: 1. Upper and Lower extremities 2. Back

CLINICAL ANATOMY INTRODUCTION OBJECTIVES OF THIS COURSE 1. Importance 2. Different anatomic structures and there interrelationships 3. Correlation of form and functions 4. Clinical application

CLINICAL ANATOMY INTRODUCTION REFERENCES: 1. Brunicardi, F. Charles, et. al., Schwartz’s Principles of Surgery, 5th ed., McGraw-Hill Medical Publishing Division, 2005, chapter 16, pp. 453-497. 2. Moore, Keith L.; Agur, Anne M. R., Essential Clinical Anatomy, 3rd ed., Lippincott Williams and Wilkens, 2007, pp. 271-489. 3. Moore, Keith L., Clinically Oriented Anatomy, Williams and Wilkens Co., 1982, pp. 419-853. 4. Netter, Frank S., Atlas of Human Anatomy, 3rd ed., Icon Learning System, 2003. 5. Snell, Richard S., Clinical Anatomy, 7th ed., Lippincott Williams and Wilkens, 1995.

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: 1. Written exam a. Long exam - Scheduled exam; no surprise examination - Clinical in nature - Case analysis b. Short quiz 2. Practical Written exam - scheduled exam - rotating type

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: Case Analysis: A 24-yr old male came to the ER due to an open wound at the posterior aspect of the left arm. Few minutes prior to ER admission, the patient was attacked by an unknown assailant with a machete. He was hit at the posterior aspect of the left arm. On PE, the following are the findings: 1. A gaping wound measuring 15 cms long and 4 cms wide and a depth of 3 cms. No foreign materials are noted within and surrounding the wound. The wound is directed obliquely from the lateral aspect superiorly to the medial aspect distally. 2. All the muscle tissues traverse by the wound are completely transected 3. The bone can be palpated underneath the wound 4. Loss of sensation at the radial aspect of the left forearm and at dorsal aspect of the left hand.

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: Case analysis(continuation) 5. Absence of active wrist dorsiflexion and the left hand assumes the position of a “wrist drop”. 6. Absence of active extension of the fingers and thumb of the left hand 7. Presence of active finger flexion of the left hand

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: -Case analysis: INSTRUCTION: Encircle the letter of the correct answer. No erasures allowed once you encircled the letter. Any erasure will not be counted and will be automatically considered against your score. You are permitted to write your trial answers at the sides of your test papers. However, once you encircle the letter, your answer is deemed final.

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: 1. The muscle group most likely injured in the posterior part of the arm is: A. Biceps B. Triceps C. Brachialis D. Brachioradialis E. Coracobrachialis 2. The muscle group mentioned in question no. 1 is collectively inserted by a common tendon to which structure? A. Radial head B. Olecranon Process C. Coracoid Process D. Coronoid Process E. None of the above 3. The nerve that innervates the muscle group mentioned in question no. 1 is: A. Median Nerve B. Musculocutaneous Nerve C. Ulnar Nerve D. Radial Nerve E. None of the above.

CLINICAL ANATOMY COURSE INTRODUCTION EXAM: 4. The “wrist drop” deformity exhibited by the left hand is due to injury of which nerve? A. Ulnar Nerve B. Median Nerve C. Radial Nerve D. Musculocutaneous Nerve E. None of the above 5. The wrist drop deformity is due to the following pathological mechanisms: A. Loss of the radial nerve innervation B. Loss of function of the wrist extensors C. Predominance of function of the wrist flexors D. Loss of median nerve innervation E. Only A, B, C are correct.

CLINICAL ANATOMY COURSE INTRODUCTION LABORATORY EXAM - Identification of structures -dissected cadaver -disarticulated skeletal parts -models - under time pressure - examination by groups - each group composed of 5 students

CLINICAL ANATOMY LABORATORY GUIDELINES 1. Respect the cadaver - “ the dead teaches the living” - Dissect for the sake of learning; don’t play with it - Disarticulated bone, models should be placed to its proper place after use 2. Dissect only when safe - Be aware that you are cutting the cadaver and not your own, or, your partner’s hand or fingers - Change nonperforming scalpel blades and forceps 3. Always use gloves and mask, and the lab gown.

CLINICAL ANATOMY COURSE INTRODUCTION DEFINITION: Human Anatomy- study of the gross or macroscopic structure of the human organism. - correlated with development, function and clinical significance ORIGIN: - oldest medical science - roots: Greek civilizations -HIPPOCRATES -ARISTOTLE DERIVATION: - “ anatome” (Greek) means cutting apart - “dissecare” (Latin) means to dissect

CLINICAL ANATOMY COURSE INTRODUCTION BRANCHES: - Human Anatomy: the mother science of clinical medicine. - offshoots: -pathology(morbid anatomy) -physiology -neuroanatomy -histology and cytology (microscopic anatomy) - embryology (developmental anatomy) - physical anthropology

CLINICAL ANATOMY COURSE INTRODUCTION OFFSHOOTS: -Subdisciplines: -clinical pathology -hematology -microbiology -immunology -cell biology -molecular biology -cellular biophysics

CLINICAL ANATOMY COURSE INTRODUCTION APPROACHES: 4 main approaches: a. Systemic anatomy b. Regional anatomy c. Functional anatomy d. Clinical anatomy

CLINICAL ANATOMY APPROACHES TO STUDYING ANATOMY A. Systemic Anatomy - organized according to FUNCTIONAL SYSTEM - Integumentary system - Musculoskeletal system - Nervous System - Circulatory System - Respiratory System - Urinary System - Endocrine system - reproductive system

CLINICAL ANATOMY APPROACHES TO STUDYING ANATOMY A. Systemic Anatomy - by ORGAN SYSTEMS Ex: skeletal, articular and muscular systems, nervous constituting the LOCOMOTOR SYSTEM - None of the organ system functions in isolation

CLINICAL ANATOMY APPROACHES TO THE STUDY OF ANATOMY B. REGIONAL ANATOMY - based on the organization of the body into parts - emphasis on the relationships of various systemic structures - each region is not an isolated part - surface anatomy: an essential part

CLINICAL ANATOMY Course introduction: surface anatomy What’s wrong with this patient? SURFACE ANATOMY - An important component of regional and clinical anatomy -the study of the surface features of body structures -fundamental aim: the visualization (in the “mind’s eye”) of structures which lie beneath the skin. - basis of PE of the body that forms a part of physical diagnosis.

CLINICAL ANATOMY

CLINICAL ANATOMY SCHEMATIC REPRESENTATIONS OF THE REGIONS OF THE BODY 8 REGIONS OF THE BODY ANATOMICAL REGIONS OF THE BODY - Head -Neck -Upper Limb -Thorax -Back -Abdomen -Pelvis/Perineum -Lower Limb

CLINICAL ANATOMY APPROACHES TO THE STUDY OF ANATOMY CLINICAL ANATOMY -EMPHASIS: structure and function as it relates to the practice of medicine and other health related professions -clinical application -encompasses both the regional and the systemic approaches Ex. Humeral fracture in the middle third of the humerus resulting in wrist drop.

CLINICAL ANATOMY COURSE INTRODUCTION ANATOMICOMEDICAL TERMINOLOGY -international vocabulary -considered to be the foundation of medical terminology -a common language for communication of health professionals EPONYMS: names of structures derived from the name of people -not officially used in anatomical terminology

CLINICAL ANATOMY Anatomical position Anatomical position with the 4 planes ANATOMICOMEDICAL TERMINOLOGY ANATOMICAL POSITION - A person standing erect with the following position of the parts of the body: - Head, eyes(gaze), and toes directed anteriorly(forward) - Upper limbs by the sides with the palms facing anteriorly - Lower limbs close together with the feet parallel and the toes directed anteriorly

CLINICAL ANATOMY Anatomical positions The anatomical planes ANATOMICAL POSITION THE ANATOMICAL PLANES -4 imaginary planes that intersect the body in the anatomical positions - 4 anatomical planes: 1. Median (median sagittal plane 2. Sagittal planes 3. Frontal (coronal ) planes 4. Transverse plane

CLINICAL ANATOMY ANATOMIC TERMINOLOGY Axis: -defined by the intersection of any two planes a. Vertical axis: defined by the intersection of the midsagittal and midcoronal planes b. Anteroposterior axes: defined by the intersection of the transverse and sagittal planes c. Bilateral axes: defined by the intersection of coronal and transverse planes.

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF RELATIONSHIP AND COMPARISON ANATOMIC TERMINOLOGY Anatomic adjectives (terms of relationship and comparison) -arranged as pairs of opposites -describe the relationship of parts to the body in the anatomical position -compare the position of two structures relative to each other.

CLINICAL ANATOMY ANATOMIC TERMINOLOGY ANATOMIC ADJECTIVES: Anterior/ posterior Proximal/ distal External/ internal Superior/ inferior Medial/ lateral Central/peripheral Prone/ supine

CLINICAL ANATOMY ANATOMIC TERMINOLOGY Commonly Used terms of Relationship and comparison: 1. Superior (cephalad, cranial, cephalic, rostral)- Nearer to the head 2. Inferior (caudal, caudad)- Nearer to the feet 3. Anterior (Ventral)-Nearer to front 4. Posterior (Dorsal)- Nearer to back 5. Medial- Nearer to median plane 6. Lateral- Farther from the median plane 7. Proximal-Nearer to trunk or point of origin (e.g., of a limb) 8. Distal-Farther from trunk or point of origin (e.g., of a limb)

CLINICAL ANATOMY ANATOMIC TERMINOLOGY Commonly Used Terms of Relationship and Comparison 9. Superficial- Nearer to the surface 10. Deep- farther from the surface 11. Dorsum- Dorsal surface of hand or foot 12. Palm- Palmar surface of the hand 13. sole- Plantar surface of foot 14. Central- toward the center of the mass of the body 15. Peripheral- away from the center of body mass

CLINICAL ANATOMY ANATOMIC TERMINOLOGY Combined terms: -describe intermediate positional arrangements -Inferomedially: nearer to the feet and closer to the median plane -Superolaterally: nearer the head and farther from the median plane PRONE/SUPINE: Prone is ventral surface down Supine is ventral surface up

CLINICAL ANATOMY ANATOMIC TERMINOLOGY Terms of Laterality: -Bilateral: paired structures having right and left members Ex: bilateral femoral shaft fractures -bilateral cystic kidneys -Unilateral: structure occuring only in one side Ex. Spleen - Ipsilateral: occuring on same side of the body Ex. Left humeral shaft fracture with ipsilateral fracture of the radius. - Contralateral: occurring on the opposite side of the body Ex: fracture of the left femur with contralateral fracture of the tibia

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT: -Describe the movements of the limbs and other parts of the body - also pairs of opposites -most movement take place at joints -movement description based on the axes and the plane -nonskeletal structures exhibiting movements: eye, tongue, lips

CLINICAL ANATOMY ANATOMIC TERMINOLOGY: TERMS OF MOVEMENT 1. FLEXION/EXTENSION -Usually occurs in the midsagittal or parasagittal planes A. Flexion: action brings primitively ventral surfaces together (e.g., bending the arm at the elbow) -Plantar flexion: downward flexion (true flexion)of the foot at the ankle joint -Dorsiflexion is upward flexion(extension) of the foot at the ankle joint. B. EXTENSION: movement away from the ventral surface( e.g. straightening the leg at the knee joint)

CLINICAL ANATOMY TERMS OF MOVEMENT 1. Flexion at the hip joint 2. Flexion at the knee joint 3. Plantar/dorsal flexion at the ankle joint 4 Inversion/Eversion movement of the foot.

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 2. ABDUCTION AND ADDUCTION a. Abduction: a movement described as moving away from the median plane of the body in the frontal(coronal) plane b. Adduction means moving toward the median plane of the body in the frontal(coronal ) plane. -motion in digits( fingers and toes): abduction –spreading the digits adduction- drawing the digits together

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 3. ROTATION: -moving a part of the body around its long (or vertical) axis. a. Medial rotation: turns the anterior(ventral) surface medially b. Lateral rotation: turns the anterior (ventral) surface laterally

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 4. ELEVATION/DEPRESSION: -Generally up and down movements about horizontal axes A. Elevation: raises or moves an anatomic part or a structure cephalad. ex. Shrugging shoulders B. Depression: lowers or moves a structure caudally ex. Moving the shoulders down

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 5. CIRCUMDUCTION -circular movement of the limbs, or parts of them -combining in sequence the movement of flexion, extension abduction and adduction

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 6. PRONATION/SUPINATION -terms used to describe a rotational motion involving the forearm and the hand a. Pronation: medial rotation of the forearm and the hand so that the palm of the hand faces posteriorly. b. Supination: lateral rotation of the forearm and the hand so that the palm of the hand faces anteriorly

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 7. INVERSION/ EVERSION - terms used to describe rotational motion of the foot a. Inversion: motion that rotates the plantar surface of the foot inward or medially b. Eversion: rotates the plantar surface of the foot laterally

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 8. PROTRACTION/RETRACTION - These are opposite terms that generally describe outward and inward movements. a. Protraction: moves a structure anteriorly Ex. Jutting out the jaw or rolling the shoulder anteriorly b. Retraction: moves the structure to its original position or to the median Ex. Withdrawing a protracted tongue into the oral cavity

CLINICAL ANATOMY ANATOMIC TERMINOLOGY TERMS OF MOVEMENT 9. Specific Movements a. Intorsion/ extorsion -terms describing eye motion -rotational motion of the eye about an axis through the pupil with the top of the eye as the reference b. Oppostion/reposition: terms describing thumb motion -uniquely a human characteristic

CLINICAL ANATOMY REVIEW OF SYSTEMS OF THE BODY SYSTEMS INCLUDED: 1. The Integument and Mammary Glands 2. The Musculoskeletal Systems

CLINICAL ANATOMY THE INTEGUMENT (SKIN) A. Surface area: less than 2 meter square -largest organ of the body B. Functions: 1. Protection -prevents fluid loss -reduces abrasive trauma 2. Sensation 3. Secretion 4. Thermoregulation 5. Synthesis and storage of Vit. D 6. Containment of tissues and vital organs.

CLINICAL ANATOMY

CLINICAL ANATOMY

CLINICAL ANATOMY The integument (skin) Schematic representation of skin THE INTEGUMENT( THE SKIN) C. DIVISIONS 1. 2 principal layers A. Epidermis- superficial layer - composed of keratin - shedding every 25- 45days - avascular B. Dermis- deep layer -regenerative - composed of interlacing collagen and elastic fibers - structures in the dermis: hair follicles sweat glands, mammary glands, blood vessels, lymph vessels, nerves and nerve endings

CLINICAL ANATOMY THE INTEGUMENT(SKIN) D. FASCIAL LAYERS 1. Fascia: plane of loose, irregularly arranged connective tissue composed of fibroblasts, collagen bundles, and some elastic fibers 2. Divisions: -Superficial fascia(Subcutaneous tissue) -Deep layer

CLINICAL ANATOMY

CLINICAL ANATOMY

CLINICAL ANATOMY THE INTEGUMENT(SKIN) -The Subcutaneous Tissue -relatively mobile in most regions of the body -Exception: Palms and Sole -composed of 2 distinct layers of superficial fascia between the dermis and the deep(investing ) fascia: a. Superficial Layer b. Deep layer

CLINICAL ANATOMY THE INTEGUMENT(SKIN) D. SUBCUTANEOUS TISSUE -Superficial Layer of Subcutaneous Tissue -called CAMPER’S FASCIA in the thorax and abdomen; CRUVEILHIER’S FASCIA in the perineum -predominantly fatty layer - structures: deepest parts of the sweat glands, blood and lymphatic vessels, and cutaneous nerves -storages for fat -PANNICULUS ADIPOSUS: layer of fat in the abdomen of overweight persons -sensitive to estrogenic hormones

CLINICAL ANATOMY THE INTEGUMENT(SKIN) E. DEEP LAYER OF THE SUPERFICIAL FASCIA(SUBCUTANEOUS TISSUE) - a membranous but thin layer made up of collagen -Fuses with the deep investing fascia -known as SCARPA’S FASCIA in the thorax and abdomen; COLLE’S FASCIA in the perineum

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Deep(investing) fascia -defines fascial planes between muscles -continuous with the covering of the structure it invest. -periosteum -perichondrium -perineurium -perimysium

CLINICAL ANATOMY THE INTEGUMENT(SKIN) -The Deep Investing Fascia -Extensions from its internal surface a. Investing fascia: invest deeper structures, such as individual muscles and neurovascular bundles. b. Intermuscular septa: divide muscles into groups or compartments c. Subserous fascia: lie between the musculoskeletal walls and the serous membranes lining the body cavities.

CLINICAL ANATOMY DEEP INVESTING FASCIA OF THE ARM DEEP INVESTING FASCIA OF THE FOREARM

CLINICAL ANATOMY THE INTEGUMENT(SKIN) Deep Investing Fascia -Specialization: 1. Retinacula 2. Bursae 3. Synovial tendon sheath

CLINICAL ANATOMY Synovial sheaths Retinacula, transverse ligaments

CLINICAL ANATOMY THE INTEGUMENT BURSA

CLINICAL ANATOMY THE INTEGUMENT (SKIN) F. Fascial planes -potential spaces between adjacent facias or fascia-lined structures. -found in living people; absent in cadavers Clinical significance: allows surgical access to deeper structures

CLINICAL ANATOMY

CLINICAL ANATOMY FASCIAL /INTERFASCIAL PLANE FASCIAL/INTERFASCIAL PLANES

CLINICAL ANATOMY THE INTEGUMENT(SKIN) G. CLEAVAGE LINES (of Langer) 1. Basis for Langer’s lines: prevailing directionality of the connective tissue bundles. -mobility of skin: due to the meshwork of collagen fibers( elastic fibers to some extent) -direction: denoted by skin creases, or, Langer’s, lines a. Thorax b. Base of neck c. Abdomen d. Extremities e. Joints f. Female breast

CLINICAL ANATOMY

CLINICAL ANATOMY

CLINICAL ANATOMY THE INTEGUMENT(SKIN) G. Cleavage Lines (of Langers) 2. Direction of the Cleavage Line a. Circumferential: Chest, base of the neck, and abdomen b. Longitudinal: along the extremities c. Female breast: circumferential to the nipple 3. Clinical Significance: breast surgery: incision made around the margin of the areola

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) -INNERVATION: -Segmental pattern -dermatome: a discrete region of skin of the wall or limb that originates from a segment. -segmental innervation comes from a pair (left and right) of mixed (afferent plus efferent) spinal nerve that supply a dermatome and myotome

REGIONAL AND CLINICAL ANATOMY SEGMENTAL INNERVATION SEGMENTAL INNERVATION Segmental Innervation of the upper extremity showing the dermatome innervated by the corresponding spinal nerve.

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Clinical Correlation: A. The Cleavage Lines of Langers: -placement of surgical skin incision a. Across the Langer’s lines: gaping wound and prominent scar formation b. Parallel to Langer’s line: few connective tissue fibers are cut; decreasing the tendency to retract and resulting in less unsightly scar -breast tumor surgery -cosmetic mammoplasty

REGIONAL AND CLINICAL ANATOMY Wrinkle skin lines Muscles of the facial expression

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Clinical Correlation: B. Segmental Innervation of the Skin 1. Spinal cord injury 2. Peripheral nerve injury C. Stretch Skin marks D. Burns E. General Medicine F. Skin Diseases

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) -Clinical Correlation B. BURNS: -tissue injuries caused by thermal, electrical , radioactive, or chemical agents. -Classification: a. First-degree burn b. Second-degree burn c. Third-degree burn - Extent of the burn(per cent of total body surface affected) more important than the severity of depth - PHYSICAL THERAPY

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Clinical Correlation C. General Medicine -Jaundice -Cutaneous manifestations of Viral Infections 1. Dengue 2. Measles 3. Herpes Zoster(Shingles) -Pallor/anemia -Acute blood loss(hemorrhage) D. Skin Allergic lesions 1. Cutaneous allergic reaction E. Diabetes Mellitus 1. diabetic ulcer

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Clinical Correlation -Diabetic Ulcer: -usually the distal part of the extremities but commonly involves the foot -ischemic in character -aggravated by secondary infection

REGIONAL AND CLINICAL ANATOMY

REGIONAL AND CLINICAL ANATOMY

REGIONAL AND CLINICAL ANATOMY

REGIONAL AND CLINICAL ANATOMY

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) The classic “butterfly rash” skin lesion of SLE Cutaneous manifestation of systemic medical condition Systemic Lupus Erythematosus (SLE) “Butterfly rash”

REGIONAL AND CLINICAL ANATOMY THE INTEGUMENT(SKIN) Clinical Correlation in Retrospect: -most commercialized - indicator of general health -vital signs -cutaneous lesions: -warning sign of a serious underlying medical problem

CLINICAL ANATOMY THE MAMMARY GLANDS (BREAST)

CLINICAL ANATOMY THE MAMMARY GLANDS THE MALE AND FEMALE MAMMARY GLAND THE BREAST Structural consideration - only well-developed in female - modified sweat glands - contour and volume of female breast -nonpregnant state -during pregnancy - breast size and shape

CLINICAL ANATOMY THE MAMMARY GLANDS Female breast SURFACE ANATOMY A. Surfaces -flattened superior surface -well defined laterally and inferiorly B. Intermammary cleft C. Areola C. Nipple Surface anatomy of the female breast

CLINICAL ANATOMY MAMMARY GLAND (BREAST SAGITTAL SECTION OF A FEMALE BREAST Structural Consideration - Retromammary space (bursa) - Suspensory ligament of Cooper - Nipple - Areola - Mammary gland lobules - Lactiferous duct - Lactiferous sinus

CLINICAL ANATOMY THE MAMMARY GLANDS VASCULATURE OF THE BREAST Arterial supply ARTERIAL SUPPLY AND VENOUS DRAINAGE 1. From subclavian artery a. Internal thoracic artery -medial mammary branches of the perforating branches -anterior intercostal branches 2. From the axillary artery -Lateral thoracic -thoracoacromial aa. 3. Thoracic aorta - Posterior Intercostal aa.

CLINICAL ANATOMY THE MAMMARY GLANDS VASCULATURE OF THE BREAST VENOUS DRAINAGE VENOUS DRAINAGE -Main venous drainage: -to the AXILLARY VAIN - Other venous drainage: to the INTERNAL THORACIC VEIN

CLINICAL ANATOMY MAMMARY GLAND Lymphatic drainage of the breast Lymphatic Drainage -role in cancer metastasis - axillary lymph nodes -pectoral -humeral -subscapular -central and apical -75% of lymph from the lateral quadrants drain to axillary lymph nodes

CLINICAL ANATOMY THE MAMMARY GLANDS THE MAMMARY GLAND LYMPHATIC DRAINAGE LYMPHATIC DRAINAGE -From medial breast quadrants: parasternal lymph nodes - inferior breast quadrants: to the abdominal lymph nodes (inferior phrenic nodes) -axillary nodes to infraclavicular and supraclavicular nodes to subclavian lymphatic trunk - parasternal nodes to bronchomediastinal nodes into thoracic or right lymphatic duct.

CLINICAL ANATOMY THE MAMMARY GLANDS THE MAMMARY GLANDS THE FOUR QUADRANTS OF THE BREAST CLINICAL CORRELATION 1. Breast Quadrants -for anatomical location and description of breast pathology ( e.g., breast cysts and tumors) -upper outer -lower outer -upper inner -lower inner

CLINICAL ANATOMY THE MAMMARY GLANDS CLINICAL CORRELATION Inflamed carcinoma of breast Breast Examination 1. Inspection 2. Palpation 3. Describing the breast lesion -location -size -mobility -tenderness -Inflammatory signs -ulceration -nipple discharges 4. Palpation of the axillary and supraclavicular nodes

CLINICAL ANATOMY THE MAMMARY GLANDS CLINICAL CORRELATION BREAST CANCER A. Risk factors for breast cancer 1. Increasing age 2. White race 3. Age at menarche <11yrs 4. Age at menopause> 55 yrs 5. Nulliparity 6. Age at first pregnancy>30 yrs 7. Absence of history of lactation 8. Prolonged use of postmenopausal estrogen replacement 9. Family history of breast cancer 10.Family history of ovarian cancer; multiple affected relatives 11. Previous breast cancer 12. Previous breast operation 13. Previous exposure to radiation

CLINICAL ANATOMY THE MAMMARY GLANDS CLINICAL CORRELATION BREAST CANCER 1. lymphatic drainage -role in metastatic spread -obstruction of the lymphatic drainage results in -lymphedema -leathery and thickened skin appearance 2. Cancerous invasion of the suspensory ligament of Cooper -dimpling of the skin 3. Orange-peel appearance (peau d’orange)- Prominent (puffy) skin between dimpled pores

CLINICAL ANATOMY THE MAMMARY GLANDS CLINICAL CORRELATION OPERATIVE PROCEDURES ON BREAST LESIONS: A. Biopsy 1. fine needle biopsy 2. open biopsy B. Mastectomy. 1. Simple mastectomy 2. Radical Mastectomy C. Lumpectomy D. Quadrantectomy

CLINICAL ANATOMY THE MAMMARY GLANDS BREAST BIOPSY SCHEMATIC REPRESENTATION OF FINE NEEDLE BIOPSY BIOPSY: - tissue sampling for histopathological studies. - kinds: a. Closed b. Open A. Closed biopsy - fine needle biopsy - Core-needle biopsy B. Open biopsy

CLINICAL ANATOMY THE MAMMARY GLANDS Surgical breast procedures Skin incisions SKIN INCISIONS 1. For small lesions -small curvilinear incision overlying the mass 2. for lesions near the nipple and areola, the periareolar skin incision is preferred

CLINICAL ANATOMY THE MAMMARY GLANDS CLINICAL CORRELATION SURGICAL PROCEDURES FOR BREAST CANCERS A. Mastectomy 1. Simple mastectomy 2. Radical mastectomy B. Breast tissue conserving surgery 1. Lumpectomy 2. Quadrantectomy

CLINICAL ANATOMY THE MAMMARY GLAND SURGICAL PROCEDURES SURGICAL BREAST INCISION SKIN INCISIONS C. For bigger and malignant lesions - transverse and curvilinear - must include previous biopsy skin incision - lower third of the hair-bearing skin of the axilla

CLINICAL ANATOMY THE MAMMARY GLAND SURGICAL PROCEDURES SAGITTAL SECTION OF BREAST Simple Mastectomy -Removal of breast tissues including the nipple and areola into RETROMAMMARY SPACE and deep pectoral fascia -End limit of the dissection: Pectoralis major muscle. -No removal of pectoral muscles Extended simple Mastectomy: removal of Level I axillary lymph nodes

CLINICAL ANATOMY THE MAMMARY GLAND SURGICAL PROCEDURES Modified radical mastectomy Modified Radical Mastectomy -Tissues to be removed: a. Breast tissue b. Nipple-areola complex c. Overlying skin d. Level I and level II axillary lymph nodes HALSTEAD RADICAL MASTECTOMY: -abandoned procedure -addition to modified radical mastectomy: all pectoralis muscles, Level I, II, III axillary lymph nodes are dissected

CLINICAL ANATOMY THE MAMMARY GLANDS BREAST TISSUE SPARING SURGERY 1. Lumpectomy 2. Quadrantectomy 3. Partial mastectomy 4. Segmental resection -standard treatment for women with stage I and stage II breast cancer -removal of primary breast cancer with a margin of normally appearing breast tissues. -adjuvant chemotherapy -assessment of axillary node status.

CLINICAL ANATOMY THE MAMMARY GLANDS REHABILITATION OF MASTECTOMY PATIENTS 1. Problems -joint stiffness: shoulder at the side of mastectomy -upper extremity postmastectomy edema -numbness of the skin overlying the mastectomy site -hypersensitivity reaction of the upper extremity ipsilateral to the mastectomy site

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM SKELETAL SYSTEM 1. COMPOSITION -bones -cartilages 2. PARTS -axial skeleton -appendicular skeleton

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM THE SKELETAL SYSTEM The bone BONE 1. Characteristics -living tissue -highly specialized -hard form of connective tissue FUNCTIONS OF THE SKELETAL SYSTEM -Protection for vital structures -Support for the body -Mechanical basis for movement -Storage for salts (e.g. calcium) -Hematopoiesis

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM THE SKELETAL SYSTEM THE SKELETAL SYSTEM AXIAL SKELETON -Head (cranium and Facial bones) -Vertebral Column (spine) -Thoracic cage APPENDICULAR SKELETON -Upper limbs - Shoulder Girdle - Pelvic Girdle -Lower limbs

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONES 1. Types a. Compact -for strength and weight bearing -greatest in the middle of diaphysis b. Spongy -load dissipating structure

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM CLASSIFICATION OF BONES ACCORDING TO THEIR SHAPE 1. Long bones 2. Short bones 3. Flat bones 4. Irregular bones 5. Sesamoid bones

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM EXAMPLES OF LONG BONES

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM EXAMPLES OF SHORT BONES

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM EXAMPLE OF FLAT BONES

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM THE MAXILLOFACIAL BONES: EXAMPLE OF IRREGULAR BONES

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONE MARKINGS AND FEATURES -Attachments of tendons, ligaments and fascia 1. Deltoid tuberosity in humerus 2. Radial tuberosity 3. lateral and medial epicondyle of the humerus -Entrance of blood vessels or neural structures 1. Nutrient foramen 2. radial groove 3. skull foramina

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF BONES SESAMOID BONES -Example: Patella -develop in certain tendons -Functions: -increase leverage -protection against excessive wear and tear

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONE MARKINGS: Condyle .Epicondyle Trochanter BONE MARKING: Line- Linea aspera tuberosity- gluteal tuberosity

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONE MARKINGS Malleolus- medial and lateral malleoli Tuberosity- anterior tibial tuberosity

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONE MARKINGS Crest- iliac crest Foramen- obturator foramen Spine- anterior and posterior iliac spines Notch- greater and lesser sciatic notch

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BONE MARKINGS Process-spinous and transverse processes Facets- Costal, articular facets Foramen-Intervertebral foramen

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM THE SKELETAL SYSTEM CARTILAGE IN SYNOVIAL JOINT LIKE THE KNEE. CARTILAGE Characteristics: -resilient, semirigid, avascular connective tissue -for smooth, low friction surface -proportion of bone and cartilage in skeleton: -young: more cartilage -adult: less cartilage

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLINICAL CORRELATION BILATERAL TALIPES EQUINOVARUS DEFORMITY (CLUBFOOT)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Clinical correlation Clubfoot deformity

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY THE MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM VASCULATURE OF BONES - Nutrient arteries -supply inner 2/3 of the bone - Periosteal arteries -supply outer 1/3 of the bone -metaphyseal and epiphyseal arteries - supply ends of bone

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM JOINTS

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM JOINTS: - Articulation, or the place of union or junction between 2 or more rigid components -between 2 bones -between 2 cartilaginous surfaces -parts of same bone Functions: -for efficient and smooth motion -a pivot point -for transfer and dissipation of forces coming from: a. muscle action b. gravity c. weight

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM ARTHROLOGY -Study of the classification, structure and function of the joints FACTORS AFFECTING THE STRUCTURE AND FUNCTION OF JOINTS: 1. Aging 2. Long term immobilization 3. disease

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS THAT FORM CONNECTIVE TISSUES WITHIN JOINTS 1. Fibers Collagen (types I and II) Elastin 2. Ground substance Glycosaminoglycans Water Solutes 3. Cells

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS 1. Fibers- Collagen and Elastic A. Collagen fibers a. Type I Collagen -relatively stiff -little stretch -primary protein in ligament, joint capsules and tendons

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Diagrammatic representation of the fibrous organization of tendons and ligaments

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS FIBERS: A. Collagen fibers b. Type II – thinner than type I - less tensile strength - make up the hyaline cartilage

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS FIBERS B. Elastin- composed of netlike interwoven small elastin fibrils -resist stretching force - found in certain spinal ligaments and the cartilage of the ear and nose

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS GROUND SUBSTANCE 1. Glycosaminoglycan(GAG) -highly branched and negatively charged amino sugars -highly hydrophilic -resembles a long bottle brushes 2. Water- provides a medium of diffusion for nutrients

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM BIOLOGIC MATERIALS GROUND SUBSTANCE CELLS - for maintenance and repair - do not confer significant mechanical properties on the tissue - sparse and interspersed between strands of fibers -or, embedded deeply in regions of high GAG content.

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM TYPES OF CONNECTIVE TISSUES THAT FORM THE STRUCTURE OF JOINTS 1. Dense irregular connective tissue 2. Articular cartilage 3. Fibrocartilage 4. Bone

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM TYPES OF CONNECTIVE TISSUES DENSE IRREGULAR CONNECTIVE TISSUE DENSE IRREGULAR CONNECTIVE TISSUE - found in fibrous external layer of articular capsule and ligaments - high proportion of type I collagen fibers -function most effectively when stretched parallel to their long axis - ground substance: GAG and elastin fibers in low proportion

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DENSE IRREGULAR CONNECTIVE TISSUE- INTERCARPAL LIGAMENTS

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DENSE IRREGULAR CONNECTIVE TISSUE: INTEROSSEOUS LIGAMENT

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DENSE IRREGULAR CONNECTIVE TISSUES: COLLATERAL LIGAMENTS OF THE KNEE.

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DENSE IRREGULAR CONNECTIVE TISSUE: ANKLE LIGAMENTS

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DENSE IRREGULAR CONNECTIVE TISSUES Ligamentous injury CLINICAL CORRELATION LIGAMENTOUS INJURIES: 1.Ligamentous stretch and laxity 2.ligament tear -incomplete -complete 3. Joint instability

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM TYPES OF CONNECTIVE TISSUE ARTICULAR CARTILAGE TYPES OF CONNECTIVE TISSUES THAT FORM THE STRUCTURE OF JOINTS ARTICULAR CARTILAGE -Specialized type of hyaline cartilage -found in load bearing surface of joints -thickness: 1-4 mm in areas of low compression force and 5-7mm in areas of high compression -avascular and aneural -absence of perichondrium

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM ARTICULAR CARTILAGE -BIOLOGIC MATERIALS -Fibers: predominantly type II collagen fibers -Ground substance: GAG -cells: chondrocytes

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM TYPES OF CONNECTIVE TISSUES THAT FORM THE STRUCTURE OF THE JOINTS FIBROCARTILAGE -much higher fiber content -has properties of both irregular connective tissues and articular cartila.ge -BIOLOGIC MATERIALS: a. fibers: type I collagen fibers b. ground substance: moderate GAG c. cells: chondrocytes -Presence of PERICHONDRIUM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CONNECTIVE TISSUES THAT FORM THE STRUCTURE OF JOINTS FIBROCARTILAGE -Distribution: -Intervertebral disc -Disc of symphysis pubis -Intraarticular discs(meniscus) of the knee joints, sternoclavicular, acromioclavicular, and distal radioulnar joints -labrum of the glenoid fossa and the acetabulum

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Fibrocartilage: intervertebral disc Intervertebral disc

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM FIBROCARTILAGE a. ideal shock absorber -menisci of knee joints -intervertebral discs of spinal column b. Perichondrium -poorly organized -small blood vessels located at the periphery of the tissue c. Aneural d. Nutrition

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM FIBROCARTILAGE: THE MENISCI OF THE KNEE LOAD DISPERSING FUNCTION OF THE MENISCUS

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Connective tissues bone TYPES OF CONNECTIVE TISSUES THAT FORM THE STRUCTURE OF THE JOINTS BONE -rigid support -provides system of levers for muscles -Architecture: -compact cortical bone makes the outer cortex -ends of long bone: outer thin layer of compact bone and inner network of cancellous bone

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Connective Tissues that form a joint Histologic organization of bone Osteon, or, haversian system -concentric lamellae -Matrix: Calcium phosphate salts: responsible for rigidity -Osteocytes in lacunae -Haversian canals -Highly vascular periosteum and endosteum HISTOLOGIC ORGANIZATION OF CORTICAL BONE

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF JOINTS 1. Basis of classification a. anatomic structure b. movement potential 2. Types of joints: a. Synarthrosis b. Amphiarthrosis c. Diarthrosis A. Synarthrosis - held together by the dense irregular connective tissue - amount of movement: allows little or no movement 1. Syndesmosis 2. Gomphosis (dentoalveolar syndesmosis)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM JOINTS AMPHIARTHROSIS ( or CARTILAGINOUS JOINTS) -Articulating bones are united by fibrocartilage or hyaline cartilage. SYNCHONDROSIS: -found in growing bones -the bony epiphysis and body are joined by an epiphyseal plate (hyaline cartilage) SYMPHYSIS: binding tissue is a fibrocartilaginous disc (e.g., between two vertebrae)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM SYNARTHROSIS JOINTS(or FIBROUS JOINTS)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DIARTHROSIS (OR SYNOVIAL JOINT) JOINTS DIARTHROSIS -Elements ALWAYS associated with diarthrodial joints: 1. Synovial fluid 2. Articular cartilage 3. Synovial membrane 4. Articular capsule 5. Capsular ligaments 6. Blood vessels 7. Sensory nerves

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM DIARTHRODIAL JOINT -Elements SOMETIMES associated with diarthrodial joints -Intraarticular discs or meniscus -peripheral labrum -fat pads -synovial plicae

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY CLASSIFICATION OF SYNOVIAL JOINTS BASED ON MECHANICAL ANALOGY 1. Hinge joint 2. Pivot joint 3. Ball and socket joint 4. Plane joint 5. Saddle joint

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF SYNOVIAL JOINT HINGE JOINT HINGE JOINT -analogous to the hinge of a door Examples: -HUMEROULNAR JOINT -Interphalangeal joints of the digits Motion allowed: -mainly rotation -slight translation (gliding)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF SYNOVIAL JOINTS Pivot joint PIVOT JOINT - formed by a central pin surrounded by a larger cylinder. -primary angular motion: spinning of one member around a single axis of rotation -mechanical analog: door knob -Anatomic example: Proximal radioulnar joint; atlantoaxial joint

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM

CLINICAL ANATOMY Classification of synovial joints Ball- and-socket joint BALL-AND-SOCKET JOINT -Primary angular motions: Triplanar motion- flexion/extension; abduction/adduction; internal/external rotation -Mechanical analog: Spherical convex surface paired with a concave cup -Anatomic examples: glenohumeral joint; hip joint (coxofemoral joint)

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF SYNOVIAL JOINTS ELLIPSOID JOINT ELLIPSOID JOINT -Primary angular motions: Biplanar (flexion/extension; abduction/adduction) -Flattened convex ellipsoid paired with a concave surface -Anatomic example: Radiocarpal joint

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF SYNOVIAL JOINTS Plane joint PLANE JOINT -Pairing of two flat or relatively flat surface -Primary angular motions: include a slide (translation) or a combined slide and rotation -Mechanical analog: relatively flat surfaces apposing one another, like a book sliding on top of a table. -Anatomic example: Intercarpal joints; intertarsal joints

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM PLANE JOINTS

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM PLANE JOINT

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLASSIFICATION OF SYNOVIAL JOINT SADDLE JOINT SADDLE JOINT -Primary angular motion: Biplanar motion -Mechanical analog: each member has a reciprocally curve concave and convex surface oriented at right angles to one another, like a horse rider and a saddle. -Anatomic example: Carpometacarpal joint Sternoclavicular joint

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM Classification of synovial joints Condyloid joint CONDYLOID JOINT -Primary angular motion: Biplanar motion; either flexion-and – extension and abduction-and-adduction, or flexion-and-extension and axial rotation (internal-and- external rotation) Mechanical Analog: mostly spherical convex surface that is enlarged in one dimension like a knuckle; paired with a shallow concave cup. Anatomic examples: metacarpophalangeal joint Tibiofemoral joint

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLINICAL CORRELATION: 1. JOINT INFLAMMATORY DISEASES a. Rheumatoid arthritis 2. DEGENERATIVE JOINT DISEASES a. Osteoarthritis 3. TRAUMATIC ARTHRITIS 3. JOINT INFECTIONS a. Bacterial septic arthritis b. Tuberculous septic arthritis

CLINICAL ANATOMY MUSCULOSKELETAL SYSTEM CLINICAL CORRELATION 1. SYNOVIAL MEMBRANE a. responsible for the inflammatory response -joint effusion: increase synovial fluid in the knee b. effective blood-knee joint barrier -not all antibiotics penetrate this barrier